Accreditation & Self Assessment
Each management practice should have its own file, complete with document that shows how the agency is in compliance with the recommended practices. The documentation should be in the form of written policies and if possible, other written documentation indicating specifics on compliance with that policy.
The ideal file should contain a single written policy, and one or two additional written documents. If policies or supporting documentation are unusually long or are part of bound document, include only that part of the document that applies to the practice in question; highlighting the appropriate area.
Documentation and Proof of Compliance. The self assessment process relies heavily on the review and analysis of existing written policies and procedures. Major discrepancies should be corrected prior to implementation of the self assessment process.
Written Policies and Procedures. These are described as policies, procedures, rules or any statement specifying a certain behavior or out come. It is strongly recommended that the written policies or procedures be supplemented with a written statement indicating how the agency has determined that they are in compliance with the policy. A single written policy can be used as proof of compliance for more than one management practice.
Other Written or Hard Copy Proof. These include the following:
- Intradepartmental memos
- Computer printouts
- Job descriptions
- State or local laws
- Letters from citizens
- Copies of investigative reports
- Newspaper clippings
- Budget documents
Non-Written Proof. Written proofs are always perceived to be the most desirable proof of compliance. However, where written proofs are not available or are less than conclusive, the following may also be used:
- Interviews. The person in charge of filing compliance documentation for a certain practice interviews the person or persons most directly involved with that practice. The interview is recorded on the compliance documentation form, along with the interviewee's name, position, phone number, and date of the interview.
- Observation. This category of proof includes verification through viewing a facility, condition, activity or object associated with a management practice.
A good tracking system to identify whether or not the agency is in compliance with the practice will ease the process. The use of an Individual Practice Status Report is one approach to document the status of each practice.
Cases of Noncompliance. An agency, for a variety of reasons, may not be able to fully comply with all of the recommended management practices. Some agencies will be able to prove that compliance with a recommended practice is not necessary because the agency does not provide or control the issue that the practice is intended to cover.
In other cases the agency may be precluded from compliance due to legal or political consideration. In these rare cases, the agency should prepare a detailed discussion of the reason that they compliance is not required and include supporting evidence in the file. Reasons for exemption include:
- Agency does not perform or control the function. There are many management practices within the manual that will not apply to your particular agency. However, before designating a certain practice as non-applicable, one must be certain that the agency neither performs nor delegates the function in question.
- Legislation or state statute may prohibit compliance with a certain practice. In this case, compliance documentation must specifically identify legislation.
- Labor Agreement. Documentation must include an excerpt from the agreement.
- Court Order or Case Citation. The specific court action case citation must be noted.
- Written Rule or Regulation. Rules or regulations that are issued from regulatory agencies having jurisdiction over the agency, such as the civil service commission, state regulatory bodies, regional governing bodies, or other public agencies.
Achieving Compliance. In cases where an agency is in non-compliance with an applicable practice, the director and program manager should meet to discuss ways of implementing the recommended practices. The director and program manager should seek input from all levels within the organization before selecting a plan of action.
Once a plan has been developed, there are no set methods for achieving compliance with the recommended practice. Many of the non-compliance issues are simple to correct during the self assessment process. Others may become multi-year projects by themselves.
Keeping Track of Progress. A master monitoring log provides an excellent means of tracking the progress of the documentation process. Kept by the assessment manager or a delegated assistant, the log includes the number of the management practice, the person responsible for documenting it, whether or not compliance has been achieved, and if necessary, the reason for noncompliance.
Review Documentation. Group Review. The completed documentation should be reviewed by a team of at least three people before submission to the director. Most agencies designate a group of individuals to act as reviewers. This group may be the self assessment team itself, or the program manager and several designated assistants or coworkers. Each member of the team reads each compliance document, and, by joint agreement, approves or rejects the documentation.
Director's Approval. Once the group is satisfied that a given practice is documented adequately, the documentation should be submitted to the director for final approval.
Peer Review. Preparing for self assessment affords your agency an opportunity to complete a thorough review of management and operations policies and practices. To verify the validity of the findings of the self assessment process of your agency may wish to work with other agencies in your area. APWA's chapters provide an excellent resource for peer review or contacts to discuss how other agencies deal with a particular practice.
Consider forming a group to meet regularly and discuss how the recommended management practices are being met. Establish review teams to assist other agencies that are participating in the group discussions. For those agencies interested in accreditation the use of peer review of the self assessment documentation may better prepare the agency for full accreditation.
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